Archives for June 2011

Your day always starts the same way. You punch in and wander outside to find the ambulance that’s going to be your home, office, break room, and personal teleporter for the next 8 (or 48) hours. Then you crack it open and figure out if it’s capable of surviving that journey.

The checkout is an integral part of your shift, and it’s not rocket science. It’s simply a process of ensuring that the equipment you’re going to need is available and functional, that you know where it is, and that anything needed is restocked or repaired before… well, before you need the darned thing.

You can go through this in a wide variety of ways, and the best process for you will depend on vagaries like how your rigs are set up, what equipment you carry, and even what’s written on your physical checklist, if you have one. But here are some general tips for optimizing things.

Start with the most critical items. That means equipment that’s essential and lifesaving, such as the AED; it also means equipment whose absence can’t be substituted, worked around, or otherwise managed. For instance, 4x4s are important — direct pressure saves lives — but there’s a dozen other types of dressings you probably have floating around, so they’re not truly essential. What’s essential?

The ambulance. If you can’t transport people, you are out of service; you are worse than useless. The first thing I do is crank the engine and make sure it catches, check for warning lights, and eyeball the fuel. If required by your service, check fluids, kick tires, whatever’s needed.

Your signal and warning devices. This is a safety issue for you and your patients. While you’re up front checking the engine, flip the lights on and check that they’re all blinking. Then key the PA microphone, listening for the audible pop (or scratch it with a nail if it’s not easily audible). If the PA works, the siren generally works, since they often use the same speakers. (Actually flipping on the siren tends to be deafening and obnoxious to everyone in earshot, so I avoid it unless the PA itself is broken.)

Next up should probably be your AED. This not only brings the dead back to life, it’s the only way of doing so unless you’re going to jerry-rig something from the truck battery and jumper cables, or try the ol’ precordial thump and prayer. Different AEDs have different maintenance procedures; most perform their own internal checks once a day at least, and you can just look for the “all’s well” symbol on the display (usually a check mark). In other cases, you’ll need to key the thing on to make sure it’s working. Check that your pads are within date (the conductive gel inside eventually dries out — this is also why the packaging should remain sealed during storage), and if it’s a model that lets you preload the wires without opening the pads, make sure there’s a set plugged in.

Look through your drugs next, if you’ve got ’em. Epinephrine is absolutely lifesaving. Aspirin significantly improves outcomes. You can’t MacGyver any of it. Make sure you have whatever minimum stock you’re supposed to have, and that it’s all in date. (Most drugs don’t suddenly turn poisonous when they hit their expiration; more often they simply become less potent. However, this is a matter of professionalism as well as liability; don’t be the guy carrying drugs 6 months past expiry.)

BVMs. At least one is essential unless you plan on giving mouth-to-mouth. Multiple sizes, or at least multiple sizes of mask, are a boon, although with proper technique you should be able to make an adult size work in most cases. Check that you not only have the BVM, but that it’s got O2 tubing, a bag, and a mask attached to it, and give the mask a squeeze to make sure the collar is filled and not leaking.

Oxygen. Check your portable tank; is it charged? (A D tank with 500psi running a NRB will run dry in about 3 minutes. Is that enough in your book?) Hold it to your ear; is the regulator leaking? If so, loosen it, check the washer, put everything in place and tighten it back down. (Remember that plastic washers are technically single-use, although they often do okay for multiple uses. Metal and rubber washers last approximately forever.) If there’s a persistent leak, leave the tank closed. And whether it’s closed or open, make sure you know which it is. If it’s closed, ensure that there’s some way of re-opening the thing, whether a wrench or an attached twist-valve. Check for adequate cannulas, masks, and nebulizers, as appropriate. Check your onboard main O2 as well.

C-spine. Got boards? Got collars? Tape? Headblocks/headbeds/towel rolls? Got enough straps to immobilize as many patients as you have boards, in whatever fashion you prefer? (Although I typically use simple arrangements like box strapping, I try to have enough straps on hand for a full chest-and-groin Grady strapping in case we’re going to be cartwheeling someone through narrow halls or spiral staircases.)

Portable suction. Is everything attached where it should be? Is there tubing and a Yankauer tip, preconnected if your service allows that? Turn it on and occlude the input port with a finger; does it suck strongly? If not at all, check for unsealed ports. If it sucks weakly, and turns over sluggishly, check the battery.

BP cuff. Unless you’ve got automatic NIBP via a monitor, this is an irreplaceable assessment tool. At least one manual cuff is necessary, but preferably there should be a full range of sizes including infant, child, adult, and a large adult or thigh cuff. Does the needle read zero? (If not, adjust it as described here). If you don’t carry your own stethoscope, you’ll obviously need one of those as well.

Now, the truck cabinets. Again, start with what’s essential — but also look for the less “essential” things you use all the time. Do the lights back here work? AC and heat? Onboard suction (same routine as for the portable)? Sheets and blankets? Maybe an extension strap on the stretcher? Gloves in your size as well as your partner’s? Paperwork? Band-aids? Put everything where you want it, whether that means the BP cuff is on the bench, emesis bags on the wall, or tissues on the stretcher. There are a million ways to organize items like OPAs and cannulas; it doesn’t matter how you do it, as long as you know where things are and how to get at them. What you don’t want is to need something, whether a BVM or a set of restraints, and have to go digging for it. What you really don’t want is to need something, go digging, and discover it’s missing.

Many less-used items may be off your radar until the day you need it. I never looked for a urinal until the first time a patient asked for it. Experience is making mistakes, as they say.

Remember that although you may not use 95% of this gear 95% of the time, you are responsible for 100% of it nevertheless, and if it’s needed and not available, your keister is on the line. And rightly so.

We’re not idiots. Everyone knows how to communicate. You just flap your jaws and blow.

In this business, though, we often find that it’s not enough to communicate; we have to do it efficiently. Likewise, it’s not enough to ask the right questions eventually. We need to do it promptly, because we’re not going to be here all day.

Heck, never mind efficiency. Sometimes there’s just a right thing to say, and everything else is wrong things. As Mark Twain put it, it’s the difference between the lightning-bug and the lightning.

So when you find a good bunch of words, you hold onto it, because like a master key, it’ll come in handy again. Here are two little phrases that everyone should have in their toolbox.

Has anything been bothering you lately?

I borrow this from Thom Dick, who suggested instead “Have you been upset about anything lately?” This is good, but to my ear leans more toward psychological troubles — very legitimate, but perhaps not what you’re after.

The patient has chest pain. Okay. Abdominal pain. Difficulty breathing. Clicky elbow. Can’t pee. So you assess their complaint from every angle, real and metaphoric, and you see what there is to see about it. But what’s the context? Is this the final stage of a grab-bag of other problems? Before it was abdominal pain, was there nausea and discomfort? Have the past few days produced a gradually increasing malaise? Is that onset truly sudden, or were there precursors?

Forget all that. Did your cat just get run over? Is your insurance refusing your reimbursements? Did your medication run out last week and you haven’t been able to afford to refill it? Are you living on ramen noodles and water?

Has anything else been bothering you? We can’t list every malady, but this question encompasses them all, and it can reveal entire storylines you wouldn’t have learned without an open-ended query. Patients have a habit of not mentioning anything that doesn’t seem directly related to their chief complaint, but those blips can make or break a clinical picture. I never call a history complete without asking it once.

How can I help?

Patients have a lot of complaints. Sometimes it’s the very reason they called you. Sometimes it’s just a complaint. They’re sick. Stuff hurts. Feels bad. Has problems.

They may share these complaints with you. And you may be able to help. Chest pain, you say? Why, I have just the morphine for that!

The trouble is, sometimes we’re not sure if we can help. Or it doesn’t seem like we can. Chest pain’s one thing. But what can you do when they complain of feeling “awful”? What about an uncomfortable stretcher — sure, let me just grab the plush memory foam? Heck, on my BLS truck, we don’t even have the morphine. We’re not magicians here.

But if you’re drawing a blank, try the wild card: ask!

Hey, sorry you’re having problems. How can I help? Often they have a solution. They’ve dealt with their problems for longer than you have. Next time, maybe you’ll have that answer on tap. But you don’t have to know all the answers; you just have to be able to ask. Funny thing, too; even when you really can’t do anything, they’re glad you cared enough to try. Sure is better than just sitting there trying to ignore their whining.

How can I help? Hey — isn’t that our whole business? They give us textbooks on how we can help. But sometimes helping’s easier than a CPAP or a trauma alert. Sometimes we can cheat, because the answer’s up for grabs. You just gotta ask.

The initial assessment (known to old-timers as the “primary survey,” but it’s all the same idea) is the first phase of patient contact. It’s the initial period where you aim your eyeballs at the human being you’re going to be caring for and uncover the most basic facts about them.

Nowadays it’s taught as a discrete series of steps, usually something like this:

General impression

Assess responsiveness: AVPU

Assess life threats: ABCs

Assess and manage airway

Assess and support breathing

Assess and support circulation

Determine patient priority

All good stuff, and there’s a reason it’s taught this way. All of these steps are important, and in order to teach (and test) them, they have to be broken down and explicitly described.

But this can be a shame, because in reality, the initial assessment isn’t like a recipe for a cake — mix this, then add that, then stir, then bake. It’s a brief burst of information, compacted into a dense flash of simultaneous sight, sound, and touch, and it can always be completed within a few seconds. In many cases it will be near instantaneous. In some it might take up to ten seconds. But it should never take as long as you’d need to actually verbalize all the steps.

The initial assessment should be a tight, elegant performance, and it’s one of the EMT’s most important skills. In the field, patients don’t come with charts or reports; all we know is what we’re dispatched with, which is usually wrong. But 90% of what you need to know about the patient can be learned promptly in the initial assessment. This is how you orient yourself to the situation and discover immediate life threats; more information and a more detailed assessment will follow, and it may reveal important findings, but our most critical job is to discover and treat what’s killing them, and that happens in the initial assessment. If you never got past this step you’d still be doing all of the most important things for the sickest people.

Here’s the process I recommend. It condenses everything you need to know into three simple steps.

Step 1: Look

You walk up and encounter your patient. What do you see?

Is he standing? Then he’s certainly conscious and alert. Is he moving purposefully or talking? Same business. Is he lying on the ground unconscious? We’ll learn more in a moment.

If he’s talking, his airway is intact and likely secure. You can roughly assess his breathing in about two seconds. Is he gasping for breath? Is he apneic? Is he speaking in full sentences?

Look at his skin. Is it pink? Is it pale and sweaty? Is it cyanotic? Is there obvious major trauma, such as significant bleeding anywhere or a puncture wound to the chest?

Step 2: Talk

Greet the patient and introduce yourself. “Hi, I’m Brandon.”

On a 911 response, you then ask for the patient’s name. How does he respond? Does he fail to recognize your presence at all? Does he look at you, but say nothing? Does he respond with a moan? Does he respond with, “George,” but his wife shakes her head and tells you otherwise? Does he promptly tell you his name?

To hear your words and verbalize an appropriate response requires alertness, engagement, memory, eye movement, vocal activity, and more. It requires the use of his airway and respiratory system, and thus reveals much about their status. Is he gurgling as he breathes? Gasping? You’ve learned a great deal already.

If you’re transferring a patient from a facility, you will already know the patient’s name, and pretending otherwise may make them wonder if you’ve got the wrong room. Better to skip their name and ask instead how they’re feeling. This leads you right into their chief complaint and subjective wellness, which is another huge slice of information. Are they in pain? Nauseous? Dizzy?

Step 3: Touch

As you talk, grasp the patient’s arm. You might politely interject, “May I grab you?” as appropriate.

Feel his skin. Is it dry, moist, or wet? Is it warm, hot, cool, or cold?

Feel his radial pulse. Is it present or absent? Is it weak, strong, or bounding? Is it slow or rapid, regular or irregular? There’s no need to count; that can wait for a full, proper set of vitals, which will come after our initial assessment. We’re just looking for a quick snapshot here.

This single touch tells you all sorts of things about his circulatory status. A patient with warm skin and a strong, regular radial pulse almost certainly has adequate volume and no immediate systemic crises. And anyway, taking someone by the hand is comforting in a primal way.

Let’s watch a few examples of this process at work.

Dispatched: MVA

Upon your arrival, you see a sedan in the middle of the road, with minor damage to the front bumper and right quarter panel. Beside it, you see an adult male walking around, slightly obese but appearing generally well.

He is ambulating easily and has no obvious bleeding or deformities. He therefore has a patent airway, largely adequate breathing and circulation, and his general impression is good. You could stop here, but we won’t.

You approach him, saying with a smile, “Hi, I’m Brandon. What’s your name?” He replies, “Greg Rogers — some idiot tried to pull out in front of me.” His breathing appears unlabored. As you talk, you take him by the wrist, feeling warm, dry skin and a strong, regular, slightly rapid radial pulse.

He appears neurologically intact, with good memory and appropriate responses. His breathing is normal and his circulation appears fine, although he is obviously a little excited.

[Initial asessment complete. Total time: 1 second to learn everything important; 5 seconds from soup to nuts. He has no life threats and is a low transport priority.]

Dispatched: Welfare check

You walk in the room to find an elderly woman supine on the bed, curled in an awkward position and motionless.

You are already highly suspicious of a depressed level of consciousness. It is possible she is merely sleeping, but most people would not sleep in such a position.

Approaching, you lean over and call, “Ma’am! Can you hear me?!” You gently shake her shoulder while you do. There is no response.

She is not alert. This is the “are you napping?” test; if she were easily roused in the same way you’d wake up your roommate, we would call her alert, not “responsive to voice”. You don’t lose points just for being asleep.

You lean into her ear and call again, this time in a loud shout. There is no response.

She is unresponsive to verbal stimuli. A loud, intrusive sound elicited no reaction.

Rolling her over, you note the sound of snoring respirations. Her chest is rising and falling with good depth, but not very quickly. Her skin is slightly ashen. You give her brachial plexus a tight pinch, to which she flinches and withdraws slightly.

She is responsive to painful stimuli, but does not open her eyes. (If you later wanted to calculate her GCS, she would earn a 5.) Her airway needs managing, and an OPA would probably be appropriate. She should receive supplemental oxygen as well, and may require assistance with the BVM. Since she’s breathing, she presumably has a pulse.

With one hand, you palpate her carotid pulse, while you palpate her radial pulse with the other. Her pulses are regular and slightly slow. Her radial is strong, and her skin is warm and dry both at the neck and at the wrist.

She has adequate circulation, perhaps with a slight bradycardia due to hypoxia. Her volume is adequate.

[Initial assessment complete. Total time: 6 seconds. She will need airway and breathing support, then a rapid assessment and transport due to her diminished level of consciousness.

Dispatched: Discharge to skilled nursing

You walk into the hospital room to find your patient in bed, semi-Fowler’s. Her eyes are open and staring at the ceiling, but she makes no acknowledgement of your presence. She is breathing adequately and without labor. Her skin appears dry and slightly pale.

She appears conscious, has an airway, and is breathing. She presumably has a pulse. She appears unremarkable for an ill but stable elderly patient, perhaps with a baseline dementia.

You approach her, saying, “Ms. Smith!” She turns her head and makes eye contact. “I’m Brandon. How are you feeling?” She replies, “Hi…” After another couple attempts, the best response she gives is to call you “Aaron” and ask about the elephants.

She is alert and engaged with her surroundings, but poorly oriented and disconnected with reality.

While you talk, you ask if you can see her arm; she pulls it slightly out from the sheets. You take her wrist with one hand. Her skin is pale, dry, and slightly cool peripherally, with poor turgor. Her radial pulse is very weak and irregularly irregular.

She is able to follow commands, but physically weak. Her peripheral circulation is poor, likely secondary to both poor cardiac output (her irregular pulse is consistent with atrial fibrillation) and peripheral vascular disease.

[Initial assessment complete. Total time: 8 seconds. Her presentation is consistent with her documented history and she is likely ready for transport.]

You may notice in all this that we haven’t performed any interventions — not even a lowly nasal cannula. The initial assessment is usually taught in a “treat as you assess” fashion; if you check the airway and find it compromised, you should address it before moving on. But look how fast we moved through all this! Wouldn’t you rather bang out your initial assessment in a few seconds, then move on to your treatments having a full knowledge of the situation? If we check the airway, and go to the trouble of sizing and inserting an OPA, by the time we’re done we still have no idea about breathing or circulatory status — something that would have taken another second or two to assess at most.

Initial assessments are like a flash of lightning: you start with nothing, and with a sudden burst of light, you end up with a great deal. That flash won’t tell you the whole story, and you’ll always need to keep looking and keep digging. But with a smart and efficient initial assessment, you’ll set the stage and choose the course for everything else to come. All in under ten seconds.

For the past ten years, he’s lived in a nursing home in a town near Boston, not too far from where he grew up. In his 60s, he’s still mentally intact, and except for the incontinence that forces him to wear a diaper, he outwardly appears well. But wending through his brain is a host of malignant tumors that will soon kill him. “The doctors” give him less than six months.

Today, we’re bringing him to see his neurologist, in an outpatient clinic for one of the large Boston hospitals. As usual, it’s been scheduled right in the middle of rush hour, so we poke along slowly through the heavy traffic and chat. I’m driving today, with a relatively new partner in back.

Richard tells us about his time in the military, running maintenance on the early WWII radar stations that would ping back from a flock of seagulls just as fast as an enemy bomber. “Seagulls are all we ever got,” he confides to us. He has a wry sense of humor and the physical carriage of someone who has been through the wringer and remains standing, even if his tanks are now mostly running on empty.

He bitterly and inconsolably describes to us how much he hates his current living situation. He spent years living on two of the facility’s other floors, and was happy — the staff were kind and competent, and he got the care he needed. Recently they relocated him to his current floor, and he can’t say enough bad things about it. The nurses are negligent and dismissive, he is ignored and manhandled — he suspects he may have run afoul of the administrator who manages the facility. I ask why he doesn’t go elsewhere; he says he wants to stay close to his doctors here. “There must be a dozen other places at least as close,” I don’t say.

When we arrive on the floor, the receptionist calls ahead inside, and then informs us that Richard won’t need to be seen today. The appointment should have been cancelled, she tells us, since he was already seen recently on other business; he can instead be rescheduled for six weeks from now. Richard throws up his hands and shakes his head, exclaiming how he knew it all along; we all wonder aloud why it couldn’t have been confirmed ahead of time over the phone.

Back into the traffic, which has only gotten thicker. I try to ease us around the potholes and I fade the radio back into the patient compartment, giving Richard some classic Beatles. He rocks out hard.

We deliver him back to his room, shake hands and head out again. As we make up the stretcher, I find myself wondering whether this nice guy, who doesn’t ask anybody for anything except his basic needs of survival, really has to die somewhere he hates.

On a notice stuck to a corkboard, I find the number for the network’s ombudsman, an impartial representative designated to act as a patient advocate for resident complaints like this one. Standing outside in the rained-on mulch, I call their office, describing Richard’s situation and asking if he can’t be transferred, if only to another floor. They promise to speak with him when they round on this building early next week.

We drive back towards the city.

It’s several weeks before I can check on him again. I do visit his room several days later, but he’s asleep, and I hate to wake him. His diaper is obviously soiled.

Three weeks after we transported him to the doctor’s appointment that never happened, I bring in Davis, one of our regular dialysis patients, who happens to share the room with Richard. A different name is on the door now, and I ask Davis hopefully if his roommate has been transferred elsewhere.